Automated testing combined with automated retraining to improve CPR skill level in emergency nurses

Full text

Learning and teaching in clinical practice
Automated testing combined with automated retraining to improve
CPR skill level in emergency nurses
Nicolas Mpotos
a
,
c
,
f
,
*
, Karel Decaluwe
b
,
1
, Vincent Van Belleghem
b
,
2
, Nick Cleymans
c
,
3
,
Joris Raemaekers
c
,
4
, Anselme Derese
c
,
5
, Bram De Wever
d
,
6
, Martin Valcke
d
,
7
,
Koenraad G. Monsieurs
c
,
e
,
f
,
8
a
Emergency Department, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
b
Emergency Department, AZ Groeninge, Loofstraat 43, B-8500 Kortrijk, Belgium
c
Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium
d
Department of Educational Studies, Ghent University, H. Dunantlaan 2, B-9000 Ghent, Belgium
e
Emergency Department, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem, Belgium
f
Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium
article info
Article history:
Accepted 19 November 2014
Keywords:
Automated testing
Basic life support
CPR
Nurses
Self-learning
abstract
Objectives: To investigate the effect of automated testing and retraining on the cardiopulmonary
resuscitation (CPR) competency level of emergency nurses.
Methods: A software program was developed allowing automated testing followed by computer exer-
cises based on the Resusci Anne Skills Station™(Laerdal, Norway). Using this system, the CPR compe-
tencies of 43 emergency nurses (mean age 37 years, SD 11, 53% female) were assessed. Nurses passed the
test if they achieved a combined score consisting of 70% compressions with depth 50 mm and 70%
compressions with complete release (<5 mm) and a mean compression rate between 100 and 120/min
and 70% bag-valve-mask ventilations between 400 and 1000 ml. Nurses failing the test received
automated feedback and feedforward on how to improve. They could then either practise with computer
exercises or take the test again without additional practise. Nurses were expected to demonstrate
competency within two months and they were retested 10 months after baseline.
Results: At baseline 35/43 nurses failed the test. Seven of them did not attempt further testing/practise
and 7 others did not continue until competency, resulting in 14/43 not competent nurses by the end of
the training period. After ten months 39 nurses were retested. Twenty-four nurses failed with as most
common reason incomplete release.
Conclusion: Automated testing with feedback was effective in detecting nurses needing CPR retraining.
Automated training and retesting improved skills to a predefined pass level. Since not all nurses trained
until success, achieving CPR competence remains an important individual and institutional motivational
challenge. Ten months after baseline the combined score showed important decay, highlighting the need
for frequent assessments.
©2014 Elsevier Ltd. All rights reserved.
*Corresponding author. Emergency Department, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. Tel.: þ32 497 301079; fax: þ32 9 3324980.
E-mail addresses: nicolas.mpotos@ugent.be (N. Mpotos), karel.decaluwe@azgroeninge.be (K. Decaluwe), Vincent.vanbelleghem@azgroeninge.be (V. Van Belleghem), nick.
cleymans@ugent.be (N. Cleymans), joris.raemaekers@ugent.be (J. Raemaekers), anselme.derese@ugent.be (A. Derese), bram.dewever@ugent.be (B. De Wever), martin.
valcke@ugent.be (M. Valcke), koen.monsieurs@ugent.be (K.G. Monsieurs).
1
Tel.: þ32 477 560971.
2
Tel.: þ32 476 484297.
3
Tel.: þ32 474 303075.
4
Tel.: þ32 487 437235.
5
Tel.: þ32 471 850063.
6
Tel.: þ32 496 950984.
7
Tel.: þ32 476 999812.
8
Tel.: þ32 478 602792.
Contents lists available at ScienceDirect
Nurse Education in Practice
journal homepage: www.elsevier.com/nepr
http://dx.doi.org/10.1016/j.nepr.2014.11.012
1471-5953/©2014 Elsevier Ltd. All rights reserved.
Nurse Education in Practice xxx (2014) 1e6
Please cite this article in press as: Mpotos, N., et al., Automated testing combined with automated retraining to improve CPR skill level in
emergency nurses, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.012

Introduction
Emergency nurses are often involved in the management of
cardiac arrest. Lack of cardiopulmonary resuscitation (CPR) skills of
nurses and physicians contributes to poor outcome of cardiac arrest
victims (Perkins et al., 2008; Passali et al., 2011; Xanthos et al.,
2012; Smith et al., 2008; Seethala et al., 2010). Despite CPR
training efforts, acquisition of compression and ventilation skills
are often poor and they decay rapidly (Chamberlain et al., 2002;
Jones et al., 2007). Nurses have a professional responsibility to
remain competent in CPR through regular updates. The use of
frequent assessments may identify those individuals requiring
additional training (Andresen et al., 2008; Castle et al., 2007; Wik
et al., 2005; Christenson et al., 2007; Niles et al., 2009). Although
recommended by the European Resuscitation Council (ERC) and by
the American Heart Association (AHA) systematic testing of
healthcare providers after a course or after a predefined interval is
still not current practice. According to Dwyer and Moser Williams
(2002) CPR training strategies that encourage nurses to update
CPR skills should be developed. The purpose of the current study
was to investigate the effect of automated testing combined with
automated retraining on the CPR competency level of emergency
nurses.
Background
As nurses are often the first professionals to encounter a person
in cardiac arrest, the effectiveness of their actions has a significant
effect on survival (Nyman and Sihvonen, 2000; Madden, 2006). It is
therefore essential that effective instructional strategies are
implemented to ensure high-quality resuscitation performance.
Some investigators (Lynch et al., 2007) stated that instructors’
judgement alone is not sufficient to determine CPR competence. As
an alternative to assessment by instructors we previously devel-
oped an automated testing station enabling formative assessment
and certification procedures in a time-efficient manner without
instructor involvement (Mpotos et al., 2012). Automated assess-
ment also offers the possibility to provide an immediate and ac-
curate test result (¼feedback) together with information on how to
further improve (¼feedforward), which according to Hattie (2009)
is the most powerful tool for learning improvement. This techno-
logical advance can reduce recertification time and allow focused
individualised retraining.
CPR skill performance is defined by the international guidelines
for resuscitation (American Heart Association and European
Resuscitation Council). These guidelines recommend that training
should be tailored to the needs of different types of learners and
learning styles to ensure adequate acquisition and retention of
skills (Soar et al., 2010). The AHA guidelines (2010) emphasize the
importance of simplification of CPR instruction to focus on
competence in the small set of skills most strongly associated with
the victim's survival. Delivery of chest compression is the CPR skill
most likely to improve survival and therefore a method for valid
determination of rescuers' competence to perform this skill is
important (Lynch et al., 2007). As such, educational interventions
need to be evaluated to ensure that they achieve the desired
educational outcomes. According to M€
akinen et al. (2007) various
methods to assess CPR skills are currently used, often with meth-
odological shortcomings. It has been stated (Wass et al., 2001) that
clinical competence should be assessed against a predefined pass
level. Since no specific CPR related research is available to propose a
benchmark, we built on general principles as derived from Mastery
Learning research indicating that a high attainment level has to be
pursued before moving to the next learning goal and that formative
assessment should be adopted to give immediate feedback. In this
context, Hattie (2009) reported that Mastery Learning approaches
result in high effect sizes (ES) when considering the impact on
learning performance (ES ¼0.58). Building on this knowledge a
combined assessment score using a 70% cut-off was established by
our research group (Mpotos et al., 2013) allowing more compre-
hensive reporting of overall CPR quality than reporting each skill
separately. However, the relative importance of each individual
skill and the exact relationship between skill level after training
and real-life CPR performance are currently unknown.
Research design
The Ethics Committee of Groeninge General Hospital (Kortrijk,
Belgium) approved the study. From March 2012 until January 2013,
43 of the 51 emergency nurses gave informed consent and partic-
ipated in the study. Eight months prior to the study all nurses had
been trained with the commercially available Resusci Anne Skills
Station™(Laerdal, Norway) computer exercises.
A self-learning station equipped with a manikin linked to a
computer was available in a small room secured with a numeric
lock, accessible 24 h a day and seven days a week (Mpotos et al.,
2011a, 2011b). For the purpose of the study, a software program
was developed to allow automated testing with feedback/feed-
forward (Ghent University, Belgium) combined with automated
self-training sessions on a CPR manikin (Resusci Anne Skills Sta-
tion™, Laerdal, Norway). As such we created short self-learning
sessions where the nurses could repetitively test or test-
practice-test until they achieved the required predefined pass
level. Practising and testing was done on a full size torso disposed
on the floor and using a bag-valve-mask device while performance
of chest compression depth, complete release, rate and ventilation
volume was registered. Each emergency nurse was invited to
perform a first automated test (resuscitate a victim of cardiac ar-
rest during 2 min) in order to establish baseline CPR skill level (T0;
basic life support). To pass the test, nurses had to achieve a 70%
combined assessment score consisting of 70% compressions with
depth 50 mm and 70% compressions with complete release
(<5 mm) and a mean compression rate between 100 and 120/min
and 70% ventilations with a volume between 400 and 1000 ml.
After each test an instant result was provided on screen (feed-
back). Nurses who failed the test were also informed about how to
improve their individual skills (feedforward). They could then
choose to perform a new test or first practice. Both could take
place immediately or at a different moment, in which case the
feedback and feedforward of the last test was recalled at the
beginning of the new session (¼feedup). Practice was done using
full CPR computer exercises (30 ventilations to two compressions)
with concurrent voice feedback (Resusci Anne Skills Station™with
limits set according to the ERC 2010 guidelines) and followed by a
new 2 min test.
All nurses were asked to achieve a pass score on the test within a
two months period (T1).
Ten months after the baseline measurement each nurse was
invited to perform a new test (T2). Before performing the new test
the result of the last performed test was displayed on screen. Not
competent nurses also received feedforward on how to improve.
Participants were sent up to three reminders in order to encourage
them to participate in the retest. The participants flow chart is
shown in Fig. 1.
Performances at baseline (T0), following training (T1), and after
ten months (T2) were compared. Proportions are reported as
counts and percentages. Confidence intervals (CI) are reported for
the differences in proportions between T0eT1 and T1eT2.
N. Mpotos et al. / Nurse Education in Practice xxx (2014) 1e62
Please cite this article in press as: Mpotos, N., et al., Automated testing combined with automated retraining to improve CPR skill level in
emergency nurses, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.012

Results
Forty-three emergency nurses participated in the study. Mean
age was 37 years (SD 11) and 53% were female. At baseline 35/43
nurses did not achieve the predefined pass level of which seven did
not attempt any further training (repeated automated testing or
practice with computer exercises). Seven others started to train but
did not continue until reaching a pass, resulting in 14/43 nurses not
achieving the pass level at the end of the two months period (Fig. 1).
Eleven nurses skipped the Skills Station™computer exercises and
succeeded by only performing repetitive tests with feedback. The
mean time to achieve success was 13 min (SD 15).
Ten months after baseline 39 nurses were retested (4 nurses
dropped out: 1 had retired,1 had left the hospital and 2 for medical
reasons) and 24 did not pass the test (T2). Six of the 14 nurses not
achieving a pass at T1 (two had attempted training but four had
only performed a baseline test) passed after ten months (Fig. 1).
The proportion of successful nurses improved for all outcome
measures after training (T1; Fig. 2) and was maintained or even
improved after ten months (T2) except for complete release (Fig. 2).
The reason for failing the test at T0 was due to failure of one skill
in 22/35 (63%) nurses, two skills in 10/35 (29%), three skills in 2/35
(6%). Only one nurse failed on all four skills. After ten months (T2)
the proportions were respectively 20/24 (83%), 3/24 (12.5%), 1/24
(4%) and 0/24 (0%). The skills most likely to fail at T0 were mean
compression rate (16/35), ventilation volume (14/35) and
compression depth (13/35). After ten months most failures were
due to incomplete release (12/24) and inadequate mean compres-
sion rate (8/24).
Complete release appeared to be the skill with the most decay
(15%) whereas the other skills were maintained or even improved.
Proportions of successful nurses at baseline (T0), at the end of
training (T1) and after ten months (T2) are reported for the com-
bined assessment score and for each individual skill (Table 1).
Discussion
At baseline (T0) the proportion of nurses achieving a pass level
was as low as 19%. This confirms the findings of other investigators
(Chamberlain et al., 2002; Jones et al., 2007) reporting rapid skill
decay. The very poor baseline level in our study might also be
attributed to the fact that, although the majority of nurses achieved
70% success for many individual skills, the combined score required
a minimum of 70% success on each of the four CPR skill
components.
Within two months, additional practice and/or formative testing
in our self-learning environment allowed most nurses to improve
their skill level to the predefined level (Table 1 and Fig. 2). The mean
time to achieve success was 13 min, which can be explained by the
fact that almost half of the nurses only performed repetitive
formative tests and skipped the additional practice. Kromann and
colleagues (2009a; 2009b) reported that testing on its own has a
learning effect. But according to several investigators the most
powerful tool for learning improvement consist in delivering
individualised feedback and feedforward after a test (Dine et al.,
2004; Hattie, 2009; Seethala et al., 2010; Andriessen et al., 2012).
That could explain the skills improvement in nurses who did not
practice with the Skills Station™computer exercises.
Fig. 1. Study design.
N. Mpotos et al. / Nurse Education in Practice xxx (2014) 1e63
Please cite this article in press as: Mpotos, N., et al., Automated testing combined with automated retraining to improve CPR skill level in
emergency nurses, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.012

After ten months 28% of the successful nurses at T1 did not
achieve the combined assessment score. Although the proportion
of successful nurses was better when compared to the baseline test
(39% vs. 19%) it still reflects poor overall group performance, con-
firming once again that individual skills rapidly decrease over time
and should be assessed more frequently. With regard to the decay
in complete release after ten months, we hypothesize that this
might be explained by an improved compression depth causing
more incomplete chest recoil. In relation to the participants who
achieved success at T3 but were unsuccessful at T2, we hypothesize
that clinical resuscitation experience that may have taken place in
the period before retesting might have had a learning effect on their
skills.
With regard to the fact that not every participant trained until
proficiency, Nyman and Sihvonen (2000) reported that nurses can
be poor at self-assessment of their resuscitation skills and therefore
Fig. 2. Cumulative proportion of participants achieving a minimal percentage of compressions with depth 5 cm (a), with complete release <5 mm (b), ventilations with volume
400e1000 ml (c), a threshold for a combined assessment score (d).
Table 1
Proportions of success at baseline (T0; n¼43), at the end of the training (T1; n¼43) and after 10 months (T2; n¼39).
Baseline (T0) End of training (T1) After 10 months (T2)
Number of
participants n/N (%)
Number of
participants n/N (%)
Difference in proportion
(T0-T1) % [95% CI]
Number of
participants n/N (%)
Difference in proportion
(T1eT2) % [95% CI]
70% Combined score
a
8/43 (19) 29/43 (67) 48% [0.33e0.63] 15/39 (39) 28% [0.14e0.42]
70% Compressions 50 mm 30/43 (70) 31/43 (72) 2% [0.02 0.06] 34/39 (87) 15% [0.04e0.26]
70% Compressions with
complete release <5mm
34/43 (79) 36/43 (84) 5% [ 0.02 0.12] 27/39 (69) 15% [0.04e0.26]
Compression rate 100e120/min 27/43 (63) 35/43 (81) 18% [0.07e0.30] 31/39 (80) 1% [0.02 0.04]
70% Ventilations between
400 and 1000 ml
29/43 (67) 32/43 (74) 7% [0.01 0.15] 35/39 (90) 16% [0.05e0.28]
a
70% combined score: 70% of all compressions 50 mm and 70% of all compressions with complete release and compression rate between 100 and 120/min and 70% of
all ventilations between 400 and 1000 ml.
N. Mpotos et al. / Nurse Education in Practice xxx (2014) 1e64
Please cite this article in press as: Mpotos, N., et al., Automated testing combined with automated retraining to improve CPR skill level in
emergency nurses, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.012

may be less likely to seek further training/update. Davies and Gould
(2000) highlighted that annual updates are insufficient in main-
taining competence and in a review on competency assessment
Allen et al. (2013) suggested testing at least once or twice a year.
This is in line with the findings of our research indicating that decay
is already noticed after ten months. Achieving or maintaining high
quality resuscitation skills is possible for every participant but
constitutes a major individual and institutional motivational chal-
lenge. The learning of practical skills is not only influenced by the
retention of factual knowledge and the performance of the skill
itself but also by the attitude of the learner (Gentle, 1972; Jonassen
and Grabowski, 1993). As highlighted by many authors
(Darkenwald and Merriam, 1982; Conklin, 1995; Dwyer and Mosel
Williams, 2002; Hopstock, 2008), the motivation to learn is
essential if education is to be successful. Facilitating the process of
learning by increasing the motivation of candidates is a complex
procedure, but is crucial to the education of adults. By applying
Knowles' (2005) principles of adult learning we can influence
motivation in many ways, by attention to the learning environment,
by providing material appropriate to the candidate's needs, and by
ensuring that instruction is carried out to the highest standards.
Implications for nurses
Our data demonstrate the feasibility to identify nurses needing
retraining by means of an automated test using a 70% combined
skills assessment score. A self-learning environment using a
formative testing strategy building on adult learning principles can
target training to the needs of each learner, allowing multiple
practice attempts. It also provides the opportunity for objective
feedback on performance together with feedforward on how to
improve, allowing learners to evaluate their CPR performance in
detail. Furthermore, the automated formative assessment proce-
dure also provides a unique opportunity for bench marking.
Nurse educators and emergency nurses should reinforce the
essential role of nurses in the management of cardiac arrest, and
without this understanding nurses might not be motivated to
participate in CPR education (Dwyer and Moser Williams, 2002). By
additionally stressing the moral and legal responsibility of every
individual to take action, this may increase motivation to achieve
proficiency and to retrain skills (Hopstock, 2008).
Limitations
No details regarding the efficacy of the CPR training prior to the
study were available. Furthermore, the nurses were not familiar
with automated assessment which may have negatively influenced
the baseline results.
Conclusions
Automated testing with feedback was effective in detecting
nurses needing CPR retraining. Additional practice and/or retesting
improved skills to a predefined pass level. Since not all nurses
trained until competency, achieving CPR competence remains an
important individual and institutional motivational challenge. Ten
months after baseline the combined score showed important
decay, highlighting the need for more frequent assessments.
Conflict of interest
We received an unrestricted grant from the Laerdal Foundation.
Laerdal Medical (Stavanger, Norway) provided the manikin and the
Resusci Anne Skills Station™licenses for the study. Laerdal has
taken no part in neither designing the study, developing the soft-
ware, analysing data nor writing of the manuscript.
Acknowledgements
We are grateful to the management of Groeninge General Hos-
pital (Kortrijk, Belgium) and to all the emergency nurses who
participated in the study. We are especially grateful to Bram
Gadeyne for the software development.
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